Jillian Horton is a physician and the author of We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing.
Last December, early Christmas morning, my friend and long-time mentor Dr. Sharon Straus was headed to the hospital. She is the physician-in-chief at St. Michael’s in downtown Toronto, the brilliant, compassionate leader behind a 475-bed health system that has now been in pandemic mode for almost three years.
She was on the corner of Queen and Victoria when she stopped and squinted. In the distance she recognized a familiar figure: one of her medical residents. He was handing out Tim Hortons gift cards to a group of people who were homeless. She watched him silently, her heart full of pride, before heading into the building.
She told me that story earlier this month, as we were talking about working in the hospital at Christmas.
“Did you write him up for unprofessional, boundary-crossing behaviour?” I asked.
We both laughed, but not for the reason you might think.
All year long, but especially in the season of giving, medicine struggles with a problem that is partly of its own making. Even at Christmas, many of us don’t know how much we can give.
Who cares if you give a patient a gift? Lots of people, apparently.
In 2013, an American doctor named Gordon Schiff wrote an article in the Journal of the American Medical Association (JAMA) about a traumatic experience. After two fruitless hours on the phone with an insurer, he’d given a patient money to purchase a medication they could not afford to buy. It wasn’t a loan and there was no coercion – there were just no other options. So Dr. Schiff reached into his pocket and gave the patient a total of $30. In JAMA, Dr. Schiff wrote that while he had “hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my ‘unprofessional boundary-crossing behaviour,’” after the resident he had been working with told the clinic directors about the event. Dr. Schiff’s paper, “Crossing Boundaries – Violation or Obligation?” was deemed so important that JAMA took the unusual step of publishing it again in 2020.
Is giving a patient a small amount of money for a prescription somehow different than giving them a Tim Hortons gift card? Dr. Schiff urges us to ask much deeper questions: When do certain “boundaries” become barriers to meaningful, caring relationships? And over time, do those boundaries make it easier for us to abdicate our deeper responsibilities to respond to suffering and the profound injustices – so vividly highlighted during the pandemic – that cruelly define many of our patients’ lives? That’s precisely why the issue matters so much. If you can’t ever facilitate the purchase of an inexpensive but desperately needed prescription, or even buy a patient who is homeless a Tim Hortons gift card on Christmas Day, what else are you going to walk away from?
We frame this issue in medical education as “professionalism” – lumping discussions about repugnant, predatory behaviour (such as sexually touching patients) in with conversations about pro-social, frankly desirable impulses such as wanting to give a patient who is freezing a winter coat. According to the Royal College of Physicians in Britain, professionalism can be defined as “a set of values, behaviours and relationships that underpin the trust the public has in doctors.”
Yet there are some who argue doctors should subordinate their personal identity to the role. This approach is incredibly confusing for young physicians trying to understand the norms of the profession they have joined. And leaving who you are at the door is completely at odds with the wise words of the late Dr. David Sackett, the “father” of evidence-based medicine, who once said that “the most powerful therapeutic tool you’ll ever have is your own personality.”
Not coincidentally, the kind, caring, patient-centred Dr. Sackett was Sharon Straus’s most important mentor. And in a curious way, since she is my most important mentor, I suppose I am one of his compassionate descendants.
Sharon’s story about her resident reminded me of a story of my own, about a patient. I’ll call her Bernice. Hailing from a Manitoba First Nation, she was the same age as my own mother and was admitted that December to our ward with a problem we were treating with pills and infusions and stern, pointless admonishments about diet and lifestyle. Pointless because when you are struggling to survive, you don’t have much bandwidth for deciding between low-fat versus full-fat milk. You are lucky if you can afford any milk, especially up north. Bernice’s bedside table was littered with pamphlets with pictures of food labels, information we kept dumping on her like fanatics. When we rounded on her, she was never looking at those pamphlets. Instead, she was looking at her hands folded in her lap, the room silent, the parking lot outside her fourth-floor window coated in a layer of pristine snow.
“She looks depressed,” one of my residents observed. “She’s always complaining how her skin is so dry. Maybe we should get psych to see her.”
“Maybe we should get psych to see her” is often a default setting on non-psychiatric wards. Feelings are sometimes treated as if they are head lice – things to be eradicated. So we called the psychiatry team to see Bernice. They are often at their busiest just before Christmas. They added her to their consult list, promising they would be by the next day.
That evening, just before I headed home, I sidestepped the prelit Christmas tree the nurses had erected in the hall, and I stopped by Bernice’s room.
I asked if I could talk to her; I sat down on the side of her bed.
“Your heart is getting stronger,” I told her. “But we notice you seem so sad.”
She was rubbing her hands together.
“They’re so dry,” she said.
“We can get you some hand lotion.”
There was a long, agonizing pause.
She only liked Oil of Olay, she told me.
And then she teared up.
The words began to spill out, along with the tears. Her daughter had died suddenly six months ago. It had been abrupt and unexpected, and the family’s life was shattered. The daughter left behind small children. She was loving and funny and always thought of the little things. She shopped for Bernice and bought her small treats. They spoiled each other with love.
Bernice had always been especially proud of her beautiful complexion, and that’s what her daughter used to buy her – Oil of Olay. She always got her a gift set at Christmas. Bernice would put it on her face and hands and everyone always said she looked so young. But now, she said, she just looked the way she felt, like a very old lady. She’d finished her last jar of face cream a few months ago. It was gone, and so was her daughter.
I sat with Bernice in that dingy room and I finally understood what was wrong with her heart.
Professionalism in nursing is, in my opinion, a little different. Nurses don’t seem to pontificate so much about keeping patients on the other side of an imaginary fence. They are often more practical – and culturally more maternal – than doctors. They see basic needs and meet them without so much pointless deliberation.
“Can you give gifts as a nurse?” I asked my charge-nurse friend Vanessa Davis, although I was sure I already knew the answer.
“Well,” she said, “I can tell you that the nurses always bought gifts for long-term patients at Christmas – shoes, boots, little radios, candies, warm blankets. But we also just brought in extra clothes or shoes or whatever those patients needed at any time of the year.” No reprimand from a boss for boundary-crossing behaviour. No need for articles in JAMA in defense of their humanity.
In his article, Dr. Schiff identified something else as problematic: tokenism. Dr. Schiff cautions us that doing just a little might leave us feeling self-satisfied, as though our work was done – excused from addressing the social and economic injustices that too often underlie patients’ suffering.
Was it “tokenism” when I left Bernice an Oil of Olay gift set from “Santa”? I don’t think it left me self-satisfied. If anything, it illuminated the bigger forces and injustices shaping Bernice’s life, ones I couldn’t change in that moment, and ones I do try to address in other arenas of my life and work.
I still think about her every time I see a bottle of Oil of Olay. I probably will for the rest of my life.
A few days before Christmas, our ward clerk, Judy, paged me to tell me a man had stopped at the desk; he wanted to give me something. It was one of the last, long-ago Christmases before the pandemic, and patients and visitors still roamed the halls freely. But I was tied up in the ER with an admission. I told Judy I’d be a while.
By the time I got up to the ward, the man was gone. Still, I passed through the double doors, past the hundreds of paper snowflakes taped to the ceiling tiles, all made and brought from home by the nurses and their children.
Judy waved when she saw me; she handed me a card.
“Don’t lose that,” she teased. “He was anxious to make sure you got it.” I recognized the name written in the upper left-hand corner. It was from a patient I’d treated a few months earlier.
Judy made me take handfuls of Christmas oranges and candy before she’d let me leave the ward. Out in the relative quiet of the hallway, I opened the envelope. A Tim Hortons gift card fell onto the ground.
Dr. Horton,
Just a quick note to again say thanks and to let you know that I hadn’t forgot our discussion pertaining to my release from hospital in time for the long weekend in Aug, where I offered to add you on my Christmas card list and you countered with the suggestion that the Christmas gift list would be better.
As you can see, you made both.
Your ever appreciative patient.
I burst into laughter. It was so damn funny my face felt like it would split from smiling. I wanted to call and thank him. But I was no longer his doctor, and the high walls around what is rightfully considered personal health information meant I couldn’t legitimately log into his medical record in order to get his phone number without the possibility of being flagged by the system for a boundary violation.
Here’s what I did with that gift card: I used it to buy myself coffee. I didn’t call a hospital ethicist to discuss whether I should keep it. I didn’t turn myself in to my professional college for unprofessional, boundary-crossing behaviour.
I just went back to my office where, in the fading light of the afternoon, I drank that one, precious coffee very, very slowly, thinking to myself how the real gifts in this job, the ones we should spend a lot more time talking about, are the people.